Healthcare Provider Details

I. General information

NPI: 1518039684
Provider Name (Legal Business Name): JOSEPH LEE DYSON JR. D.D.S.,PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 06/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 LIBERTY HEIGHTS AVE
BALTIMORE MD
21207-7052
US

IV. Provider business mailing address

4901 LIBERTY HEIGHTS AVE
BALTIMORE MD
21207-7052
US

V. Phone/Fax

Practice location:
  • Phone: 410-542-7877
  • Fax: 410-542-7884
Mailing address:
  • Phone: 410-542-7877
  • Fax: 410-542-7884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number8597
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: